The diagnosis of narcissistic personality disorder does not in and of itself imply a given treatment. Because the range of narcissistic character pathology is broad, the reasons for seeking treatment multiple, and the capacities and circumstances of the patients varied, treatment must be tailored to each individual case. Motivation, insight, and life circumstances need to be taken into account in formulating a realistic treatment plan and treatment goals. Narcissistic personality disorder presents in a full range of severity, from episodically troublesome dysphoria to crippling existential emptiness and lack of meaningful relationships and goals, and treatment is prescribed accordingly.

No controlled comparative treatment studies for narcissistic personality disorder have been conducted, and treatment recommendations therefore are based on clinical experience. Although some form of individual psychotherapy is generally recommended, couples, family, and group therapy are useful modalities in certain cases.

Pharmacotherapy is indicated for treatment of comorbid Axis I conditions such as dysthymia, other affective disorders, or anxiety disorders, but no known pharmacological treatment is effective for the character disorder itself. Similarly, hospitalization of patients with narcissistic personality disorder may be of use in the treatment of comorbid Axis I disorders but is not known to have any direct benefit in the treatment of the personality disorder.

Individual Therapies

The capacities and motivations of the patient are important considerations in choosing and recommending a form of individual therapy. The patient’s general ego strength (as measured by the quality of personal relationships, historical capacity for love and feelings of guilt, anxiety tolerance and impulse control, and potential for sublimatory commitment in an area of life such as work or a passionate hobby) is an important guide to the choice of treatment. Kernberg highlighted the “quality of internalized object relations,” meaning “the depth of the patient’s internal relationships with others, rather than the extent to which he [or she] is involved in social interactions” as perhaps the most critical indicator for type of treatment.

Psychoanalysis or exploratory psychotherapy at least twice a week may be indicated for narcissistic patients who have adequate ego strength and object relations but significant life impairments. For narcissistic patients with overt borderline or antisocial features, psychoanalysis or intensive exploratory psychotherapy must be approached with caution. A supportive-expressive psychotherapy with clear limit setting and less potential for regression is probably preferable in treating such narcissistic patients. Recently, treatments that combine the directive aspects of cognitive-behavioral therapy with interpretive, transference-based psychodynamic techniques have been formally studied and proposed as an additional model in the range of approaches to narcissistic personality disorder. In clinical practice, such eclectic approaches are often used, and we believe that such treatments are likely in the future to take their place alongside psychoanalytically derived psychotherapies.

Brief Therapy
Patients with narcissistic personality disorder who are troubled by limited neurotic symptoms and maintain apparent satisfactory adaptation in other areas of their lives are unlikely to be sufficiently motivated to tolerate the demands of psychoanalysis or psychoanalytic psychotherapy. Short-term psychotherapy is probably the best treatment in such cases. The goal of such treatment is generally to improve adaptation rather than to alter character. These patients, who are generally young and whose narcissism is often well compensated by their life circumstances, may return for treatment later in life as their narcissistic pathology makes further inroads into their interpersonal relationships, their professional endeavors, or their general sense of pleasure. At these later times, they may be capable of greater insight into their need for more intensive psychotherapy.

Oldham, for example, described a 24-session, once-weekly psychotherapy for a 50-year-old surgeon who came to treatment under threat of divorce from his wife and in the setting of his daughter’s hospitalization for depression. The patient’s chronic rage attacks, periods of dysphoria, and tyrannical style at work and in the home came to the boiling point under the stress of his daughter’s illness and were threatening to destroy the family.

Oldham diagnosed narcissistic personality disorder based on DSM criteria, along with an adjustment disorder with mixed emotional features. His treatment choice and strategy of a time-limited psychotherapy were based on “a dynamically informed directive approach”. Recognizing that narcissistic character structure is “especially ego-syntonic, and unlikely to be altered in brief treatment”, he also understood that midlife deterioration represented a window of opportunity for insight and change on the part of the patient. He therefore set the treatment goal as increased insight and modification of destructive behavior patterns. He approached the patient empathically, acknowledging that the patient’s “survivor mentality” grew out of the circumstances of his upbringing. At the same time, he did not endorse the patient’s view of his problems as stemming from a lack of appreciation and mistreatment by others. Instead, he consistently pointed out the patient’s role in generating and perpetuating his life problems and defined the patient’s task to be “refraining from acting on impulse, and deliberately trying to see things from the point of view of the other person”. These behavioral efforts were gradually reinforced by the family’s more positive responses to the patient. The treatment ended with the patient asking to be able to return at a future date to touch base with the therapist. Highlighting the masochistic side of the narcissistic coin, Oldham concluded that “the narcissistic patient whose pathology leads to dismantling his own success may be highly receptive to treatment at such a critical point.”

Psychoanalysis and Psychoanalytic Psychotherapy
When character change is the goal and ego strength is adequate, psychoanalysis or intensive psychoanalytic psychotherapy is indicated. There are two dominant paradigms for the psychoanalytic treatment of narcissistic personality disorder. One is associated with self psychology and the work of Kohut; the other is associated with the ego psychology-object relations theory and the approach of Kernberg.

Where Kohut sees structural deficits in the self, Kernberg discovers pathological defensive organization; where Kohut finds hidden elements of positive transference, Kernberg perceives latent negative transference; and where Kohut advises the unimpeded efflorescence and empathic encouragement of narcissistic idealization, Kernberg insists on its early interpretation. If for Kohut and his students it is above all the narcissist’s overwhelming and hidden shame that must be recognized and understood, for Kernberg envy lies like a minotaur at the heart of the narcissistic labyrinth and must be gotten at in therapy (

Table 85-2).

Although for heuristic purposes it is useful to contrast sharply these two perspectives on pathological narcissism and its treatment, it is important to recognize that at times they also complement each other. Taken together, they create a dual perspective on narcissistic personality disorder and furnish the therapist with a complex and comprehensive way of listening to, understanding, and treating these patients. Moreover, they offer the therapist treatment options that can be used and assessed for appropriateness and therapeutic effect with each narcissistic personality disorder patient. We urge a flexible and individualized approach to each patient with narcissistic personality disorder, in which the therapist uses conceptualizations and recommendations from both Kohut and Kernberg, to the extent that they fit the therapist’s overall theoretical biases and personality traits. One cannot treat narcissistic personality disorder without the conviction concerning one’s therapeutic activity and without the therapist’s inner sense of honesty, of being true to himself or herself as a therapist. Without this, the therapist will collude with the patient’s “false self” and will engage in a sham treatment that can only be ineffective.

Self Psychology/Kohut
Kohut treats the narcissistic patient’s insistent demand for mirroring admiration from the therapist as the pathological consequence of the arrested development of potentially healthy narcissistic needs. He envisions the narcissist’s transference, including aloofness and devaluation, as disguised desires for acceptance by, merger with, and imitation of the therapist. These transference forms indicate the failure of adequate development of the self to such a degree that the individual is unable to experience reliable self-esteem and self-soothing and needs to use the therapist as a primitive selfobject through whom to obtain them. Kohut contends that a therapist who allows himself or herself to be so used will create a therapeutic environment within which the arrested development can be resumed and the deficient structures of the self built.

The sine qua non for successful treatment is the therapist’s capacity to allow the patient to develop a mirroring, idealizing, or twinship transference and to refrain from early interpretation of the patient’s grandiosity and narcissistic conflicts. Empathic understanding and explanation, rather than interpretation of defenses, are the therapist’s therapeutic tools early in the treatment. By empathy, Kohut means an attunement with the patient’s inner affective life that allows the therapist to understand what each situation, including the treatment, feels like to the patient.

In Kohut’s view, the patient’s original narcissistic needs were not met empathically by the parental selfobjects, and therefore potentially healthy self strivings were arrested and secondarily became distorted. They then manifest themselves as defensive and compensatory arrogance, coldness, contempt, and isolation. An empathic therapeutic relationship revives the childhood hope for empathic responses to narcissistic needs for confirmation, union, and imitation and is the basis for successful treatment.

For example, in explaining to the patient “the protective function of the grandiose fantasies and the social isolation,” the therapist must do so “without censure” and thereby “demonstrate that he [or she] is in tune with the patient’s disintegration anxiety and shame concerning [the patient’s] precariously established self.” Maintenance of a safe, nonattacking atmosphere will allow the emergence of “the spontaneously arising transference mobilization of the old narcissistic needs,” which have been shamefully denied, hidden, and repressed by the patient. This will enable the patient slowly to experience his or her “need for the selfobject’s joyful acceptance of [the patient’s] childhood grandiosity and for an omnipotent surrounding - healthy needs that had not been responded to in early life.” If the therapist can maintain an atmosphere in which these long-buried needs are allowed to flourish, they will “gradually - and spontaneously - be transformed into normal self-assertiveness and normal devotion to ideals”.

Not each failure of therapeutic empathy injures the treatment. On the contrary, the inevitable “microempathic failures” that occur during the course of treatment are occasions for crucial therapeutic work. As long as the therapist is empathically attuned to the patient’s narcissistic needs and therefore is functioning either as the admiring-accepting mirror or as the idealized source of strength and security, the patient is likely to experience a sense of self-cohesion and well-being. However, following a failure of empathic attunement by the therapist - for example, in an erroneous interpretation or an attitude that misreads the patient’s affective need - the patient will present with symptoms of self-fragmentation, such as hypochondriasis or a lapse into the defensive posture of coldness and devaluation or rage. By reconstructing and interpreting the sequence of events that led to the empathic rupture and the recrudescence of these narcissistic symptoms, the bond can be restored, the early infantile failures inferred, and the defensive nature of the symptomatology illuminated.

Countless such repetitive sequences of frustration of narcissistic needs followed by empathic interpretation of those needs lead to the “laying down of [missing] psychic structure”. This building of deficient self structure takes place through a process of “transmuting internalization” whereby the patient internalizes the therapist’s selfobject functions. The patient is gradually able to resume the derailed process of healthy narcissistic development and to shape ambitions and ideals to conform more closely to his or her abilities.

The work of Kohutian analysis demands of the therapist not only empathic introspection but also careful scrutiny of his or her own narcissistic responses to the patient. The therapist’s wishes for admiration and gratitude, anxiety at the patient’s grandiose idealization of him or her, or anger at being treated as a mere extension of the patient could lead to countertransference acting-out. The patient’s need to oppose and reject the therapist is understood by self psychologists as part of an “adversarial selfobject transference,” in which self-cohesiveness is maintained and self-development furthered by the therapist’s acceptance of such a stance. Untimely, critical interpretations of the patient’s denigration of, opposition to, or idealization of the analyst will lead to further shameful repression of the patient’s healthy childhood narcissistic strivings under the patient’s crust of clamorous assertiveness or shy withdrawal.

Shame is a core affect of narcissism, reflecting, in the language of self psychology, “not conflicting drives, but passive failure, defect, or depletion”. Shame and humiliation drive into hiding the patient’s wishes for empathic reflection and a strong object to idealize. The reemergence of these wishes within therapy thus depends on the patient’s, as well as the therapist’s, ability to accept the patient’s painful feelings of shame, and with them, the weaknesses of the self. Empathic immersion in the life of the patient, aided by introspection (but not revelation) by the therapist concerning the therapist’s own feelings of shame about his or her defects, will create an atmosphere in which the patient is able to recognize and admit his or her own limitations and the therapist is able to accept them.

Ego Psychology-Object Relations/Kernberg
Kernberg emphasizes the pathological and defensive nature of the narcissistic individual’s grandiose self, including demands for mirroring and idealization of the therapist. The treatment focuses on establishing and interpreting a narcissistic transference, with the aim of uncovering the patient’s envy and rage, and clarifying their link to unfulfilled longings for loving care from a maternal object. In this way, the patient’s defensive narcissistic structure is loosened if not relinquished and the capacity for intimacy and meaningful object relations enhanced.

For Kernberg, consistent interpretation of the negative transference is the sine qua non of successful analytic work with narcissistic patients. “What appears as distance and uninvolvement on the surface,” he contends, “is underneath an active process of devaluation, depreciation, and spoiling”. This negative transference, in which the narcissistic individual devalues and denigrates the analyst and the analytic work, threatens to turn the analysis into a sham, a meaningless game. It may take subtle forms, such as pseudocompliance, in which the patient appears to acknowledge the analyst’s interpretations while actually ignoring them, or less subtle forms, such as the undoing in one session of the work of the previous one. Sudden switches in the emotional attitude of the patient, for example, after moments of correct interpretation that briefly yield relief or emotional connection, further “rob the analyst of his [or her] interpretation” and devalue the analyst’s worth. The therapist may begin to experience himself or herself as ineffectual, incompetent, invisible, and needing to work harder, with feelings of anxiety before the patient’s sessions and impotent frustration and self-doubt afterward.

These countertransferential feelings are important diagnostic and therapeutic data that the therapist ignores at the peril of the treatment. Indeed, the recognition and proper use of countertransference in the treatment are critical in working with narcissistic patients. Because the patient treats the therapist as an extension of the self, the patient is likely to induce in the therapist certain states that reflect what the patient is struggling with. Therefore, Kernberg advises that [the therapist] should bring the countertransference into the analytic process, not by revealing to the patient what his own reaction is, but by consistently recognizing in the countertransference the hidden intention of the patient’s behavior. For example, when the patient systematically rejects all the analyst’s interpretations over a long period of time, the analyst may recognize his own resultant feelings of impotence and point out to the patient that he is treating the analyst as if he wished to make him feel defeated and impotent.

Because narcissistic patients are likely to “bring out the worst in their therapists” by inducing in them feelings of anger, confusion, boredom, or lifelessness, it is especially important to scrutinize one’s countertransference responses before using them for therapeutic purposes. In particular, via projective identification, the narcissistic patient can bring about insensitive, unempathic, attacking responses if the therapist loses sight of the fact that these reflect the patient’s inner state.

Idealization of the therapist by narcissistic patients is viewed by Kernberg as a pathological process rather than the reactivation of a normal developmental stage, and as such its interpretation is a crucial focus of Kernberg’s therapeutic approach. The narcissistic individual’s early idealization of the therapist may combine fantasies of the therapist’s perfection with a total lack of curiosity about the therapist’s life outside the treatment. This idealization can be understood as a projection of the patient’s grandiose self onto the therapist and a denial of the therapist’s separateness. The idealization thus serves as a defense against feelings of rage and envy (of the therapist’s life and work), as well as against projected sadistic wishes that the patient experiences as fear of attack from the therapist. Its latently negative aspect, of treating the therapist as if he or she were not really there, may be experienced by the therapist as a sense of emptiness, like being a hollow crystal shell. It may trigger anxieties revolving around the therapist’s own narcissism. The interpretation of this early idealization is considered by Kernberg crucial to successful treatment, so as to prevent the creation of a sham treatment and to help uncover the underlying affects and fantasies against which the grandiose self has been constructed.

Interpretation exclusively of the latent negative aspects of the transference without acknowledgment of the positive aspects runs the risk of the patient experiencing the therapist’s interpretations as moral condemnation that the patient is “all bad.” It is therefore essential that the therapist also focus on any signs of the patient’s capacity for love and affection, including his or her genuine appreciation of the therapist, and on the “positive” functions of the narcissistic defenses. The therapist should keep in mind and interpret the ways in which the narcissistic defenses are used by the patient to protect the therapist from the patient’s underlying affects and thereby preserve the therapeutic relationship. By maintaining a balance between the interpretation of these two functions of the narcissistic defenses - defending against the patient’s awareness of his or her underlying envy and rage on the one hand and protecting the therapist from their imagined destructiveness on the other - the therapist can maintain a noncritical atmosphere within which the patient can safely yield his or her defensive structures.

A crucial and dangerous period of treatment follows the systematic interpretation of the pathological narcissistic defenses. The patient may experience paranoia from projection of his or her exposed rage onto the therapist-as-mother, as well as severe depression and guilt from the realization of the destructive effects of the narcissism on the patient’s past life and relationships. With adequate ego strength on the part of the patient and an appreciative attitude on the part of the therapist, the patient can work through and accept these feelings and begin to experience the therapist and others in his or her life as independent beings toward whom he or she can feel positive affections. The patient simultaneously begins to experience an enriched sense of his or her own inner life and may “come alive” for the first time in the treatment. The transference then takes on the form of a classical transference neurosis.

Overview
The theoretical and technical debate between Kernbergian and Kohutian models of narcissistic pathology and its treatment remains unresolved, despite at least one attempt to test their competing claims. Their conflicting psychotherapeutic strategies would seem to brook no compromise. In practice, however, one can benefit from the insights and recommendations of both treatment paradigms without adhering strictly to either one.

Our clinical approach to narcissistic patients resembles that of Bromberg, who advocates a flexible therapeutic stance toward the patient, in which the therapist is constantly monitoring and adjusting the balance between empathy and anxiety in the therapeutic atmosphere in order to create and maintain an alliance with the patient and simultaneously push him or her toward greater self-awareness.

In the early phase of treatment, the balance between empathic acceptance and interpretive challenging is weighted toward the former. Interpretations are, in the words of one therapist, “smuggled across narcissistic lines”. They are not interpretations of the transference per se but rather are intended simultaneously to show the therapist’s understanding of the patient and to accustom the patient to looking at and reflecting upon himself or herself:

For example, highlighting the use of detachment or self-containment as a means of avoiding the experience of inadequacy when he [or she] needs more than he [or she] can get, is a formulation that the patient can accept and even begin to work with on a surface level without it threatening the narcissistic base of the transference itself.

This early phase resembles Kohut’s model of treatment. We believe, however, that even - or especially - in this early phase, failure to address subtle expressions of devaluation can serve to create a sham treatment and ultimately undermine the therapy. The interpretations at this point may be aimed primarily at informing the patient that the therapist is aware of the patient’s rage, will not retaliate, and understands that the patient cannot simply stop it.

As treatment progresses, however, the therapist helps the patient confront more directly the preconscious affects and fantasies that lie beneath the narcissistic defenses. In our view, the therapist needs to push these patients to grow beyond the fantasy of entitlement that they need not work for themselves, that the therapist can and will do all the work. The therapist pushes the patient by calling on the patient’s newfound capacity for self-observation that was strengthened in the previous phase of the treatment. Now the same issues that were addressed nontransferentially can be explored in the transference. Underlying feelings of rage and emptiness that were defended against by the grandiose self come to the surface. The therapy begins to resemble a Kernbergian treatment.

In our experience, the personal style and theoretical orientation of the therapist will, and should, determine the therapeutic approach to the narcissistic patient. In order to carry out these often emotionally taxing treatments, the therapist benefits from the theoretical positions and therapeutic guidance provided by both paradigms. Of course, each therapeutic path, if followed blindly, has its pitfalls: a tendency toward indulgence and pity on the one hand and scolding and blame on the other.

Rather than strict adherence to a technique, we favor commitment to an attitude of empathic appreciation of defenses and their timely interpretation. The therapeutic approach to the narcissistic patient (as used with other patients in psychotherapy but even more so when faced with the specific countertransferential challenges posed by narcissistic patients) requires an understanding of narcissistic dynamics and the maintenance of an empathic stance based on that understanding. We urge the therapist to listen empathically for the patient’s experience and simultaneously to be aware of the effect it is having, and may be intended to have, on him or her. Almost by definition, patients with narcissistic personality disorder are more fragile than they appear, and therefore premature interpretation of defenses is likely to drive them away - either literally out of treatment or emotionally away from the therapist into a posture of aloofness or pseudocompliance. Narcissistic personality disorder patients generally require an extended period of treatment before they are truly able to accept or receive the therapist’s interpretations. At the same time, as discussed earlier, devaluation that goes unacknowledged is likely to spoil the possibility of future effective therapeutic interventions and therefore must be noted and explored empathically.

We urge the therapist to keep in mind certain fundamental aspects of the dynamics of narcissistic pathology. First, the narcissistic patient’s relationships - including his or her relationship with the therapist - are narcissistic; therefore, he or she will treat the therapist as an extension of himself or herself, as a gratifying or depriving selfobject, as admired or contemptible, and as idealized or worthless. In each case, it is worth wondering and trying to understand what aspect of himself or herself the patient is responding to and defending against in attributing these qualities to the therapist. Moreover, the primitive harshness of the patient’s inner conscience and his or her efforts to defend against it through projection as well as contempt and devaluation should not be lost sight of in the treatment. His or her defenses also should be thought of as his or her adaptations - to the family environment in which he or she developed and to the inner psychological environment in which he or she continues to live. Indeed, an alliance gradually can be established when the therapist lets the patient know that he or she recognizes the internal pressures the patient is under from his or her relentless and insatiable demands on himself or herself and when the therapist seeks to understand the sources and emotional consequences of living with such inner demands. The therapist’s nondefensive attitude of understanding without indulgence or pity, without scolding or blame, can help the patient assume a fuller, richer, more empathic attitude toward himself or herself and ultimately toward others as well.